Failure to Document and Investigate Resident Grievance Regarding Incontinence Care
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident's grievance was formally documented, investigated, and resolved according to the facility's grievance policy. The resident, who was cognitively intact and dependent on staff for mobility and transfers, reported being left on the call light for 4-5 hours while needing incontinence care after their ostomy bag broke, resulting in feces exposure. The resident attempted to get assistance by calling the main facility phone number multiple times, and although several staff responded to the call light, they did not provide the necessary care. The Director of Social Services was notified of the resident's repeated calls and visited the resident's room, but did not initiate a formal grievance or document the concern. The Nursing Home Administrator, who is designated as the facility's grievance official, was aware of the incident but did not gather further details, obtain staff statements, or conduct an investigation. Both the Director of Social Services and the Nursing Home Administrator acknowledged that a formal grievance should have been initiated and investigated, but this was not done. The facility's policy requires that all grievances, including verbal complaints, be documented, investigated, and resolved promptly, with written decisions issued to the resident. In this case, the facility staff did not follow these procedures, resulting in the resident's expressed care concerns not being formally addressed or investigated as required by policy.